Osteoarthritis and Cartilage 25 (2017) 94e98

Development of a valid Simplified Chinese version of the International

Hip Outcome Tool (SC-iHOT-33) in young patients having total hip
arthroplasty
D.H. Li y a, W. Wang z a, X. Li x a, Y.L. Gao y, D.H. Liu k, D.L. Liu k, W.D. Xu k *
y Department of Orthopedics, The Eighty-eighth Military Hospital, Hushan Road 6, Tai'an, 271000, China
z Department of Orthopedics, Chengdu Military General Hospital, Tianhui Road 270, Chengdu, 610000, China
x Department of Sports, Tai Shan University, Dongyue Road 525, Tai'an, 271000, China
k Department of Orthopedics, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Shanghai, 200433, China

a r t i c l e i n f o s u m m a r y

Article history: Objective: The International Hip Outcome Tool (iHOT-33) is a questionnaire designed for young, active
Received 20 February 2016 patients with hip disorders. It has proven to be a highly reliable and valid questionnaire. The main
Accepted 30 August 2016 purpose of our study was to adapt the iHOT-33 questionnaire into simplified Chinese and to assess its
psychometric properties in Chinese patients.
Keywords: Method: The iHOT-33 was cross culturally adapted into Chinese and 138 patients completed the Western
iHOT-33
Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the EuroQol-5D (EQ-5D), and the
Simplified Chinese version
Chinese version of the iHOT-33(SC-iHOT-33) pre- or postoperatively within 6 months' follow-up. The
Hip disorders
Cronbach's alpha, intraclass correlation coefficient (ICC), Pearson's correlation coefficient (r), effect size
(ES), and standardized response mean (SRM) were calculated to assess the reliability, validity, and
responsiveness of the SC-iHOT-33, respectively.
Results: Total Cronbach's alpha was 0.965, which represented excellent internal consistency of the SC-
iHOT-33. The ICC ranges from 0.866 to 0.929, which shows excellent testeretest reliability. The sub-
scales of SC-iHOT-33 had the highest correlation coefficient (r ¼ 0.812) with the physical function
subscales of the WOMAC, as well as good correlation between the social/emotional subscale of the SC-
iHOT-33 and the EQ-5D (r ¼ 0.740, r ¼ 0.743). No floor or ceiling effects were found. The ES and SRM
values indicated good responsiveness of 2.44 and 2.67, respectively.
Conclusion: The SC-iHOT-33 questionnaire is reliable, valid, and responsive for the evaluation of young,
Chinese, active patients with hip disorders.
© 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Introduction suggested that a new PRO questionnaire to evaluate younger pa-

Patient-reported outcome (PRO) scales are usually reflected in
the form of questionnaires. For young patients with hip problems,
the design and validation of PRO scales was carried out in patients
undergoing hip arthroscopy.
Initially, surgeons adopted the Hip Outcome Score (HOS) to
assess the effect of arthroscopic surgery1,2. However, Thorborg
* Address correspondence and reprint requests to: W.D. Xu, Department of Or-
thopedics, Changhai Hospital Affiliated to the Second Military Medical University,
Changhai Road 168, Shanghai, 200433, China.
E-mail addresses: bzmcldh@163.com (D.H. Li), shanghaildh@hotmail.com
(W.D. Xu).
a
Contributed equally.
tients (age <50) with hip and/or groin disability should be
developed2. Subsequently, Tijssen et al. conducted a new sys-
tematic review in which they compared three questionnaires.
Finally, they recommended using a combination of the Non-
arthritic Hip Score (NAHS) and the HOS for young patients un-
dergoing hip arthroscopy3. A study by Kemp et al. looked at the
Copenhagen Hip and Groin Outcome Score (HAGOS), the Hip
Disability and Osteoarthritis Outcome Score (HOOS), the Inter-
national Hip Outcome Tool (iHOT-33), the Modified Harris Hip
Score (MHHS), and the HOS, and found that the HOOS and the
iHOT-33 appeared to be the most appropriate, current measures of
outcome in young patients who have undergone hip arthroscopy4.
A recent study by Thorborg showed that the HAGOS, the HOS, the
iHOT-12 (this is the simplified version of the iHOT-33), and the

http://dx.doi.org/10.1016/j.joca.2016.08.013
1063-4584/© 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
 D.H. Li et al. / Osteoarthritis and Cartilage 25 (2017) 94e98 95

iHOT-33 are recommended for the assessment of young-to mid-
dle-aged adults with hip pain5.
The iHOT-33 is the first evaluative tool designed to measure
health-related quality of life in young, active patients with hip
disorders6. The iHOT-33 has been studied and proven reliable, valid,
and responsive for patients with hip disorders4,6. It also has been
translated into several languages such as German, Spanish, and
Portuguese7e9. Therefore, this study aimed to perform a cross-
cultural adaptation of the iHOT-33 for the Chinese-speaking pop-
ulation with hip disorders and evaluate the psychometric proper-
ties of the Chinese version in Chinese patients undergoing hip
arthroplasty.
patients signed the informed consent to participate in the study
and the clinical research ethics committee of our hospital approved
the study (No.CHEC2014-217). Additionally, the sample size met the
criterion from a previous study11, that suggested that the study
should have at least 100 patients enrolled for an internal consis-
tency analysis and 50 patients enrolled for floor or ceiling effects
and reliability and validity analysis. At the same time, we reviewed
a similar study8, and taking into account that some subjects would
be lost to follow-up, we decided the sample size should be at least
120 patients.
Instruments

Materials and methods
Translation and cross-cultural adaptation
As previously described, the translation process has a standard
guideline, which we replicated10. There are five steps in the process.
The translation from English to simplified Chinese was indepen-
dently performed by three bilingual translators and then the first
Chinese version of the iHOT-33 was obtained after translation
disagreements were resolved by discussion. The back translation
was performed by three international medical students whose first
language is English. Next, the first Chinese version and the English
version were compared to solve any remaining problems and the
final Chinese version of the iHOT-33 was obtained: the SC-iHOT-33.
The final version was tested on 30 consecutive young patients with
hip disorders.
Participants
From August 2014 to May 2015, we invited a total of 150 patients
with only one affected hip to participate in this study and 138
consecutive young patients (84 males, 54 females) with hip disor-
ders were recruited. The inclusion criteria were as follows: age >18
years and <60 years, able to read and speak Chinese, hip disorders
diagnosed uniformly in our hospital and another hospital, active
score 4 on a modified Tegner Activity Scale, and willing to receive
a total hip arthroplasty (THA) in our hospital. Patients were
excluded if they were unable or unwilling to complete the ques-
tionnaire or if they had comorbid medical conditions that lead to
hip pain or interfered with their ability to lead normal and activ-
ities6. The mean age of our participants was 43.3 years (range,
18e60 years). More detailed information is listed in Table I. All 138
The iHOT-33 questionnaire consists of four domains (symptoms
and functional limitations, sports and recreational activities, job-
related concerns, and social, emotional, and lifestyle concerns)
totaling 33 questions. Each question is answered through a visual
analog scale (VAS) response format and generates an overall score
ranging from 0 to 100, with a higher score representing better hip
status. The final score is the average of the scores from the 33
questions. The iHOT-33 has been translated and validated into
several languages at this point in time7e9.
In order to evaluate the construct validity of the iHOT-33, we
compared it with the WOMAC and the EQ-5D. The WOMAC is a self-
reported questionnaire used for patients with knee or hip osteo-
arthritis (OA) and includes three subscales (pain, stiffness, and
physical functioning) with 24 items. Each item is rated on a scale of
0e4, and the final score of each subscale will be the summation.
The higher the score, the worse the quality of life it represents. The
EQ-5D is a standardized instrument used to measure health out-
comes. It is composed of two parts. Part 1 involves five questions
and scores range from 0.111 (worst quality of life) to 0.848 (best
quality of life). Part 2 offers a VAS for the patients through which
they score their physical health12. Both the WOMAC and the EQ-5D
have been translated into simplified Chinese, with good validity,
reliability, and responsivity13,14 and have been used to evaluate the
construct validity of the iHOT-33 in other studies7,8.
Patients recruited in this study completed the SC-iHOT-33, the
WOMAC, and the EQ-5D when they decided to undergo THA in the
clinic. Two weeks later, prior to surgery, they were asked to com-
plete the questionnaires for the second time. Six months after the
THA, patients were required to complete the SC-iHOT-33 for the
third time during a return visit.
Statistical analysis

Statistical analysis was performed by using SPSS (Version 20.0;

Table I SPSS Inc., Chicago, IL, USA) and Winsteps Rasch measurement
Demographic and clinical characteristics of participants computer program (Version 3.72.3 WINSTEPS, Berkeley, CA, USA).
Characteristics Number or mean ± SD Mean values were reported with standard deviation (SD). In the
text that follows, SD represents the standard deviation, not stan-
Age 43.3 ± 11.2
Range 18e60 dard error. Intraclass correlation coefficient (ICC), effect size (ES),
Gender and standardized response mean (SRM) values were reported with
Female 54 (39.1%) 95% confidence intervals (CIs). P values < 0.05 were considered
Male 84 (60.9%) significant.
Affected side
Right 79 (57.2%)
Left 59 (42.8%) Acceptability and score distribution
Dominant side
Dominant 73 (52.9%) To evaluate acceptability, patients were asked whether they had
Nondominant 65 (47.1%)
encountered any difficulties. An answering-loss ratio of each item
BMI 25.8 ± 4.9
Diagnosis exceeding 5% was considered noneffective15, so we checked the
Avascular necrosis 64 (46.4%) data to assure every term was effective. In addition, we analyzed
Hip dysplasia 48 (34.8%) the score distribution and tested whether the questionnaire con-
FAI 26 (18.8%) tained a floor or ceiling effect. If the extreme value was under 15%,
FAI: Femoro-acetabular impingement syndrome. the questionnaire was acceptable.
96 D.H. Li et al. / Osteoarthritis and Cartilage 25 (2017) 94e98
Reliability
We assessed the reliability of the SC-iHOT-33 by internal con-
sistency and testeretest reliability. Internal consistency was
measured by Cronbach's alpha11. The value was judged as accept-
able (alpha >0.7), good (alpha >0.8), or excellent (alpha >0.9).
Furthermore, we measured testeretest reliability by comparing the
first and second time-points scores. The ICC was used to assess the
testeretest reliability16, where a value > 0.6 was considered good
reproducibility and a value > 0.8 was considered excellent. A
BlandeAltman plot not only described the mean scores of the two
assessments and the differences between them, but it was used to
assess whether there was systematic bias between the test and
retest of the SC-iHOT-3317,18. In addition, we calculated each sub-
scale's scaling success rates to observe if any scaling error existed19.
The subscale's scaling is the percentage of the items that correlate
higher with their own subscales than with the questionnaire's
other domains.
Validity
We evaluated construct validity by calculating Pearson's corre-
lation coefficients (r) among the SC-iHOT-33, the WOMAC, and the
EQ-5D. The construct validity was regarded as poor, fair, moderate,
good, or excellent when r ¼ 0e0.20, r ¼ 0.21e0.40, r ¼ 0.41e0.60,
r ¼ 0.61e0.80, or r ¼ 0.81e1.0, respectively20. Good construct val-
idity means that a questionnaire correlates well with measures of
the same construct (convergent validity) while poor construct
validity correlates with measures of different constructs (divergent
or discriminant validity). It was hypothesized that the physical,
mental, and social subscales in the SC-iHOT-33 were strongly
correlated with those in the WOMAC and the EQ-5D. Under that
assumption, we calculated the r-value between each scale of SC-
iHOT-33, the WOMAC, and the EQ-5D.
Responsiveness
The responsiveness of the SC-iHOT-33 was evaluated by
comparing the preoperative and 6-month postoperative scores. In
addition, we had the paired t-test of the scores in two rounds and
calculated ES and SRM to determine responsiveness21. The ES was
calculated by the mean change between the preoperative and 6-
month postoperative results divided by the SD of the preopera-
tive score. The SRM was calculated by the mean change between
the preoperative and 6-month postoperative results divided by the
SD of the change between preoperative and 6-month postoperative
results.
Results
Acceptability and score distribution
The average time required to complete the SC-iHOT-33 was
10.5 min, and participants expressed no difficulties in completing
the questionnaire. We calculated the answering-loss ratio in the
four subscales, ranging from 0% to 5.1%. Owing to the particularity
of item 28, which relates to sexual activity, it had the highest
answering-loss ratio (5.1%). The distribution of the scores among
the four subscales is displayed in Table II, and no floor (0%e
2.2% < 15%) or ceiling effect (0% < 15%) was detected.
Reliability
The ICC results were either very good or excellent for the sub-
scales. Cronbach's alpha was 0.965 for the overall SC-iHOT-33 and
ranged from 0.852 to 0.957 (see Table II). The SC-iHOT-33 showed
excellent testeretest reliability. Mean score of the retest was
32.36 ± 14.18 (mean ± SD), which was similar to the first test
(32.65 ± 12.28) (mean ± SD). Moreover, the ICC value is
0.866e0.929 (Table III). As previously described, ICC >0.80 indi-
cated excellent reliability18. In addition, we observed that each
subscale enjoyed 100% scaling success rates and no scaling error
existed. Moreover, no systematic error was discovered in the
BlandeAltman plots as we previously charted (Fig. 1).
Validity
The construct validity evaluation results obtained by comparing
the SC-iHOT-33 subscales vs the WOMAC and the EQ-5D are shown
in Table III. The results were consistent with our prior hypothesis in
the pre-research period. The correlation between the SC-iHOT-33
and the subscale of physical activities (0.802, P < 0.001) was
excellent. The subscales of symptoms and functional limitations in
the SC-iHOT-33 had the highest correlation coefficient of r ¼ 0.812
with the physical function subscales of the WOMAC. The correla-
tion between the social/emotional subscale of the SC-iHOT-33 and
the EQ-5D was good (r ¼ 0.740, r ¼ 0.743).
Responsiveness
The SC-iHOT-33 showed good responsiveness to surgery. The
responsiveness of the SC-iHOT-33 was evaluated by comparing the
pre- and postoperative scores. The mean score of the SC-iHOT-33
improved from 32.65 ± 12.28 to 62.65 ± 9.07 with a mean
change of 30.00 ± 11.24. The ES and SRM for the SC-iHOT-33 were
2.44(95% CI, 2.24 to 2.59) and 2.67(95% CI, 2.41 to 2.93),
respectively.
Discussion
Young patients with hip disorders have a higher demand for the
ability to return to sports, heavy physical activity, and quality of life
compared to older patients8. Therefore, it is not suitable to evaluate
the operation effect by adopting ordinary scales developed for older
patients. For example, the WOMAC has been widely used in clinics
by Chinese orthopedic surgeons, but it is actually more suitable for
older patients with arthritis and was developed for use in an older
population.
In our opinions that the reason of arthroscopic surgery is not
popular with orthopedic surgeons in China are complicated, the
economic status of patients is one reason, but the primary reason is
arthroscopy's poor effect. Therefore, people will be more willing to
accept THA and patients undergoing THA in China are ideal can-
didates for the iHOT-33 adaption. Moreover, when Mohtadi et al.8
developed the iHOT-33, patients who underwent THA were part
of the inclusion criteria.
We evaluated the reliability by internal consistency and
testeretest reliability. Each subscale of the SC-iHOT-33 contained
good internal consistency, as all Cronbach's alpha values were over
0.8. As for the testeretest reliability, the ICC of each subscale was
also over 0.8. The BlandeAltman plots proved that the SC-iHOT-33
had good reproducibility. In addition, the scaling success rates of all
of the subscales were 100%, which implied that no scaling error was
found in each item. All the results discussed previously were
equivalent to other studies of the iHOT-339.
We evaluated the construct validity of the SC-iHOT-33 by
calculating the correlation between the SC-iHOT-33, the WOMAC,
and the EQ-5D. The obtained results nearly matched the previously
presumed results. It is suggested that the SC-iHOT-33 had very
good convergent validity and divergent validity. It was evident that
 D.H. Li et al. / Osteoarthritis and Cartilage 25 (2017) 94e98 97

Table II
Distribution and internal consistency for the subscales of the SC-iHOT33*

Subscale Mean ± SD Missing items Observed range Theoretical range Floor Ceiling Scaling Cronbach's ES
n (%)y effect (%)z effect (%)z success (%)x alpha

Total 32.65 ± 12.28 0 (0%) 3.6e68.5 0e100 0 0 100 0.965 0.024

Symptom 27.01 ± 11.38 0 (0%) 0e66.9 0e100 1.4 0 100 0.932 0.023
Sports 31.49 ± 16.89 0 (0%) 0e78.3 0e100 2.2 0 100 0.873 0.017
Job 49.06 ± 18.73 1 (0.7%) 0e87.5 0e100 0 0 100 0.852 0.018
Social 37.16 ± 13.34 7 (5.1%) 0e81.4 0e100 1.4 0 100 0.957 0.024

SC-iHOT33: Simplified Chinese version of the International Hip Outcome Tool-33; SD: Standard deviation.
*
The sample size for the analysis of score distribution and internal consistency was 138.
y
Number of patients with some missing items in the subscale, and the ratio in parentheses is the questionnaires exists missing items.
z
Percentage of patients with the worst (floor effect) and the best (ceiling effect) score.
x
Percentage of the items that correlate higher with their own subscales than with the other domains of the questionnaire.

Table III
Construct validity, reliability, and responsiveness of the SC-iHOT33*

Parameter SC-iHOT33 subscale (No. items)

Symptom (16) Sports (6) Job (4) Social (7) Total (33)

Construct validity indicated by Pearson correlation coefficient, r (P value), vs indicated instruments

WOMAC
Pain 0.791 (<0.001) 0.664 (<0.001) 0.553 (<0.001) 0.729 (<0.001) 0.792 (<0.001)
Stiffness 0.723 (<0.001) 0.563 (<0.001) 0.526 (<0.001) 0.690 (<0.001) 0.722 (<0.001)
Physical function 0.812 (<0.001) 0.623 (<0.001) 0.585 (<0.001) 0.753 (<0.001) 0.802 (<0.001)
EQ-5D
Five dimensions 0.716 (<0.001) 0.603 (<0.001) 0.567 (<0.001) 0.705 (<0.001) 0.740 (<0.001)
Health status (VAS) 0.744 (<0.001) 0.644 (<0.001) 0.467 (<0.001) 0.700 (<0.001) 0.743 (<0.001)
Testeretest reliability, mean (SD) or ICC value (CI range)
Test score 27.01 (11.38) 31.49 (16.89) 49.06 (18.73) 37.16 (13.34) 32.65 (12.28)
Retest score 26.74 (13.31) 31.20 (17.99) 48.72 (19.87) 36.84 (15.76) 32.36 (14.18)
Score change 0.27 (6.22) 0.28 (6.57) 0.34 (7.89) 0.33 (7.57) 0.29 (6.78)
ICC (95% CI) 0.874 (0.828e0.908) 0.929 (0.903e0.949) 0.917 (0.886e0.940) 0.866 (0.818e0.902) 0.870 (0.823e0.931)
Responsiveness pre-THR vs 6 months after THR, mean (SD)
Pre-THR score 27.01 (11.38) 31.49 (16.89) 49.06 (18.73) 37.16 (13.34) 32.65 (12.28)
Post-THR score 58.24 (11.55) 58.47 (19.34) 84.11 (16.22) 64.04 (18.55) 62.65 (9.07)
Score change 31.23 (15.47) 26.98 (16.52) 35.05 (20.47) 26.88 (15.00) 30.00 (11.24)
Effect size (ES) 2.74 (2.64e2.87) 1.60 (1.45e1.87) 1.87 (1.61e2.03) 2.01 (1.82e2.17) 2.44 (2.24e2.59)
SRM 2.01 (1.79e2.37) 1.63 (1.41e1.82) 1.71 (1.44e1.98) 1.79 (1.61e1.96) 2.67 (2.41e2.93)

SC-iHOT33: Simplified Chinese version of the International Hip Outcome Tool-33; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; EQ-5D:
EuroQol-5 Dimensions; SD: Standard deviation; ICC: Intraclass correlation coefficient; CI: Confidence interval; THR: Total Hip Replacement; SRM: Standardized response
mean.
*
The sample size for the analysis of construct validity, reliability, and responsiveness was 138.

the symptoms/function subscale of the SC-iHOT-33 shared good or

Fig. 1. This is BlandeAltman plot for testeretest reliability of the SC-iHOT33. Each data
point indicates how the difference between the two test sessions for an individual
patient compares with the mean of the two sessions for scores of iHOT33. The interval
of two sessions was 2 weeks. The dashed line shows the 95% (±1.96 SD) limits of
agreement.
excellent correlation (0.723e0.812) with the WOMAC, especially
the physical function subscale. The job-related concerns subscale of
the SC-iHOT-33 only showed moderate correlation with the
WOMAC. We hold the opinion that patients continue to work even
though they may feel pain or uncomfortable, and that in some
cases, pain or stiffness could be relieved by medicine or support
measures. Whatever the influence of the hip disorder on job or
physical discomfort, it must have an impact on emotional or inner
feelings, so the emotional and lifestyle concerns subscale of the SC-
iHOT-33 showed good correlation with the EQ-5D. None of the four
subscales had a floor or ceiling effect, and this matches the other
validation study data as well9,10.
The ability of the SC-iHOT-33 to detect change is quantified by
the ES and SRM. This ability is called responsiveness or sensitivity
to clinical change, which is the most important characteristic in a
prospective outcome study. The results showed that the SC-iHOT-
33 was able to detect change after surgical treatment with
excellent responsiveness. The ES and SRM of the SC-iHOT-33 were
2.44 and 2.67, respectively. Our research showed that all subscales
of the SC-iHOT-33 had a steady increase in average value and its
reactive indicators 6 months after the arthroplasty, which was
better than other studies9,10. Our explanation is that the partici-
pants in our study had a worse health status than those of other
validation studies, so that is why our participants preferred to
98 D.H. Li et al. / Osteoarthritis and Cartilage 25 (2017) 94e98
have arthroplasty rather than arthroscopy, which might lead to
better responses to surgical treatment.
However, a few limitations of this study should be addressed.
First, cultural diversity about sex is obvious. The 28th question,
“How much trouble do you have with sexual activity because of
your hip?” had the highest answering-loss ratio. As the previous
study explained, the reasonable explanation is that the Chinese
culture is more private and people are ashamed to talk about sex or
sexual activity in public14. Second, all the patients in our study
selected THA rather than arthroscopic surgery, therefore it is
necessary to recruit patients undergoing arthroscopic surgery in
the future.
Summary
This study confirmed that the iHOT-33 could be translated into
simplified Chinese with good psychometric properties. As a self-
reported questionnaire, the SC-iHOT-33 is a joint-specific, reliable,
valid instrument for young Chinese patients undergoing hip
arthroplasty for hip disorders. Therefore, we recommend that
surgeons in clinics use the iHOT-33 to evaluate the impact of hip
discomfort and help assess the treatment effects on patients
younger than 60 years old.
Author contributions
Dahe Li, Wei Wang, and Xia Li contributed equally to the manu-
script, they conceived and designed the study and performed the
statistical analysis; Yulei Gao, Denghui Liu, and Delin Liu collected
the clinical data; Weidong Xu Approved the final version.
Conflict of interest
There is no conflict of interest.
Acknowledgements
We are grateful for the help of three international medical
students for the translation. We also show a sincere gratitude to the
guidance of statistical analysis from associate professor Xia Li. This
study has no funding sources.
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